INTRODUÇÃO: Racional: A alta atividade plaquetária residual (AAPR) em uso do AAS é considerada um fator de mau prognóstico em portadores de síndrome isquêmica miocárdica instável (SIMI). Adicionalmente, as taxas de prevalência de AAPR verificadas em diferentes estudos realizados na fase aguda das SIMI são consideradas elevadas em relação às verificadas em portadores de doença arterial coronariana estável. Todavia, não está bem demostrado se essa elevada prevalência de AAPR diagnosticada na fase aguda das SIMI representa um fenômeno transitório, desaparecendo na fase tardia, ou se é um estado permanente, independente da fase aguda. MÉTODOS: O objetivo primário do presente estudo foi o de comparar, em pacientes com SIMI sem supradesnível do segmento ST, a resposta antiplaquetária ao AAS nas fases aguda e tardia na mesma população. Foram incluídos 70 pacientes com SIMI sem supradesnível de ST (77% com angina instável e 22% com IAM sem supra de ST), com idade média de 64,97 anos, sendo 54% do sexo feminino, todos em uso de AAS na dose de 100 a 200mg por pelo menos sete dias anteriores à inclusão. Os pacientes foram submetidos a cinco testes de agregação plaquetária na fase aguda, e os mesmos testes foram repetidos na fase tardia, três meses depois: VerifyNowAspirin®, agregometria de sangue total (AST) com ácido aracdônico (AA) e colágeno, tromboxane B2 sérico, PFA-100. RESULTADOS: De acordo com os testes COX-1 específicos (VFN e AST com AA), a AAPR em uso do AAS foi mais prevalente na fase aguda das SIMI do que na fase tardia (VFN: 32,1% versus 16%, p=0,049; e AST com AA: 31,4% versus 12,8%, p=0,015). Os testes não específicos (AST com colágeno, PFA) e o teste bioquímico não conseguiram demonstrar diferenças entre as fases. A correlação entre os cinco testes realizados foi considerada fraca ou moderada. CONCLUSÃO: A alta prevalência de AAPR, apesar do uso da AAS durante as SIMI, reflete mais provavelmente um estado de hiper-reatividade plaquetária transitória, que se reverte na fase crônica e estável da DAC, de acordo com os testes COX-1 específicos. A correlação entre os testes plaquetários foi apenas moderada nos dois cenários / BACKGROUND: The high residual platelet activity (HRPA) in response to acetylsalicilic acid (ASA) is considered a poor prognostic factor in patients with acute coronary syndromes (ACS). Additionally, the HRPA prevalence rates reported by different studies in ACS patients are considered high compared to those reported in patients with stable coronary artery disease. However, it is not well demonstrated whether this high HRPA prevalence diagnosed during the acute phase represents a transient phenomenon, disappearing in the late phase, or if it is a permanent state, independent of the acute phase. The aim of this study was to compare platelet aggregation in response to ASA during the ACS acute phase with the platelet aggregation in chronic stable phase. METHODS: Inclusion of patients with non ST ACS who were on aspirin at a dose of 100mg to 200mg per day for at least seven days prior to inclusion. We conducted five tests of platelet aggregation in the first 48 hours and repeated them three months later: VerifyNow Aspirin® (VFN), Whole Blood aggregometry (WBA) with arachidonic acid (AA) and collagen, thromboxane B2, PFA-100®. We analyzed 70 patients (77% with unstable angina and 22% with non ST AMI), mean age 64.97 years, 54% female. According to the COX-1 specific tests, the HRPA was more frequent in the acute phase than in the chronic phase (VerifyNowAspirin®: 31.4% versus 12.8%, p=0.015; and WBA with AA: 32.1% versus 16%, p=0.049; respectively). The non specific tests (AST with collagen and PFA) and the biochemical test sTXB2 failed to show differences between the phases. The correlation between the five tests was considered weak or moderate. CONCLUSION: The high prevalence of RPA despite the use of aspirin during the acute phase of the SCA most likely reflects a state of transient platelet hyperreactivity, which is reversed in the chronic phase. The correlation between platelet tests was only moderate in both scenarios

A avaliação do estado de saúde percebido tem sido um tema de pesquisa imprescindível na área da saúde, visto que seus resultados contribuem para definir tratamentos, avaliar custo/benefício do cuidado, além de reduzir as taxas de morbimortalidade. Os objetivos deste estudo foram: comparar a presença de sintomas, o estado de saúde percebido e o grau de severidade da depressão, segundo o diagnóstico da Síndrome Isquêmica Miocárdica Instável (SIMI): Infarto Agudo do Miocárdio (IAM) versus Angina Instável (AI); investigar a presença de possíveis relações entre o estado de saúde percebido e o grau de severidade da depressão nos dois grupos e analisar a variância da medida do estado de saúde percebido e do grau de severidade da depressão explicada por variáveis preditoras. Estudo descritivo, correlacional e transversal, desenvolvido na Unidade Coronariana e enfermarias da cardiologia de dois hospitais públicos do interior de São Paulo. Entrevistas individuais foram realizadas pela pesquisadora com a coleta de dados para caracterização sociodemográfica e clínica, questionário de sintomas associados à SIMI, avaliação do estado de saúde percebido (SF-36) e depressão (Inventário de Depressão de Beck). Os dados foram analisados utilizando o teste de associação (Qui-quadrado), teste t de Student para amostras independentes e o teste de correlação de Pearson. Foram construídos cinco modelos de regressão linear múltipla, a fim de se verificarem as porcentagens da variância que eram explicadas por cada uma das variáveis preditoras. O nível de significância adotado foi de 0,05. Participaram da investigação 253 pacientes, sendo 142 diagnosticados com IAM, com idade média de 55,8 anos e a maioria homens (74,6%). No grupo de AI (111 pacientes), a idade média foi de 60,6 anos, e a maioria também foi do sexo masculino (62,2%). Com relação ao estado de saúde percebido, pode-se observar que as melhores avaliações foram relatadas pelos pacientes que sofreram um IAM, assim como apresentaram menor grau de severidade de depressão do que quando comparados com pacientes com AI. Foram observadas correlações negativas entre o estado de saúde percebido e a depressão nos dois grupos de pacientes, sendo de forças fracas a forte no grupo de infartados e de moderadas a forte no grupo de angina, todas são estatisticamente significantes. Utilizando como variáveis preditoras o sexo, a idade, a presença de tratamentos prévios para doenças cardiovasculares e a manifestação da SIMI, foram obtidos valores de R2 ajustados de 0,138; 0,231; 0,129 e 0,117 para os domínios Aspectos Físicos, Capacidade Funcional, Dor e Aspectos Emocionais, respectivamente. A inclusão da medida de depressão e o uso de psicofármacos elevaram os valores para 0,251; 0,349; 0,259 e 0,263, todos são aumentos estatisticamente significantes. Com relação ao modelo construído para a depressão, utilizando as mesmas variáveis preditoras dos modelos anteriores, o R2 ajustado encontrado foi de 0,149. Conclui-se que os pacientes com AI apresentaram maior comprometimento em todos os domínios avaliados pelo SF-36, quando comparados com os pacientes com IAM, assim como reportaram maior grau de severidade de depressão. Além disso, pacientes com maior grau de depressão apresentaram piores avaliações do estado de saúde percebido. / Perceived health state assessment has been a fundamental research theme in health, as its results contribute to define treatments, assess the cost/benefit of care and reduce morbidity/mortality rates. This research aimed to: compare the presence of symptoms, the perceived health state and the severity degree of depression according to the diagnosis of Acute Coronary Syndrome (ACS): Acute Myocardial Infarction (AMI) versus Unstable Angina (UA); investigate the presence of possible relations between perceived health state and the severity degree of depression in the two groups and analyze the variance in the perceived health state and the severity degree of depression measure explained by predictive variables. Study descriptive, correlational and cross-sectional, developed at the Coronary Unit and cardiology wards of two public hospitals in the interior of São Paulo, Brazil. The researcher held individual interviews, collecting sociodemographic and clinical characterization data and applying a questionnaire on ACS-associated symptoms, an instrument to assess the perceived health state (SF-36) and depression (Beck Depression Inventory). Data were analyzed using the association test (Chi-square), Students t-test for independent samples and Pearsons correlation test. Five multiple linear regression models were constructed to verify the variance percentages explained by each of the predictive variables. The significance level was set at 0.05. Research participants were 253 patients, 142 of whom were diagnosed with AMI, with an average age of 55.8 years and mostly men (74.6%). In the UA group (111 patients), the average age was 60.6 years and patients were mostly male (62.2%) too. With regard to the perceived health state, the best assessments came from patients victims of AMI, who also presented minor severity degree of depression when compared with UA patients. Negative correlations were observed between perceived health state and the severity degree of depression in both patient groups, which were weak to strong in the infarction group and moderate to strong in the angina group, all statistically significant. Using gender, age, presence of previous treatments for cardiovascular diseases and ACS manifestations as predictive variables, adjusted R2 levels amounted to 0.138; 0.231; 0.129 and 0.117 for Physical Aspects, Functional Capacity, Pain and Emotional Aspects, respectively. The inclusion of the depression measure and the use of psychotropic drugs raised levels to 0.251; 0.349; 0.259 and 0.263, all statistically significant increases. With regard to the model constructed for depression, using the same predictive variables as in earlier models, the adjusted R2 was 0.149. In conclusion, all SF-36 domains were more committed among patients with UA than among patients with AMI. UA patients also reported higher severity degree of depression more frequently. Moreover, patients with higher severity degree of depression presented worse assessments of the perceived health state.

Background: Religious involvement is widespread and may influence patient engagement with their healthcare (patient activation) and health outcomes. This dissertation examined the association between religiosity and patient activation, changes in health-related quality of life (HRQOL), readmissions, and survival after hospitalization for acute coronary syndrome (ACS). Methods: We recruited 2,174 patients hospitalized for ACS in Georgia and Central Massachusetts (2011-2013) in a prospective cohort study. Participants self-reported three items assessing religiosity – strength/comfort from religion, petition prayers for health, and awareness of intercessory prayers by others. Patient activation was measured using the 6-item Patient Activation Measure. Generic HRQOL was assessed with the SF-36®v2 physical and mental component summary scores. Disease-specific HRQOL was evaluated with the Seattle Angina Questionnaire Quality of Life subscale. Unscheduled readmissions were validated from medical records. Mortality status was obtained from national and state vital statistics. Results: After adjustment for several sociodemographic, psychosocial, and clinical variables, reports of strength/comfort from religion and receipt of intercessions were associated with high activation. Praying for one’s health was associated with low activation. Prayers for health were associated with clinically meaningful increases in disease-specific and physical HRQOL. Neither strength/comfort from religion, petition, nor intercessory prayers were significantly associated with unscheduled 30-day readmissions and two-year all-cause mortality. Conclusions: Most ACS survivors acknowledge religious practices for their health. Religiosity was associated with patient activation and changes in HRQOL. These findings suggest that religiosity may influence patient engagement in their healthcare and recovery after a life-threatening illness, buttressing the need for holistic approach in patient management.

Proton pump inhibitors (PPIs) are commonly coadministered with clopidogrel, an antiplatelet agent, to patients with acute coronary syndrome (ACS). Mechanistic studies suggest that PPIs have the potential to competitively inhibit the bioactivation of clopidogrel and may attenuate its antiplatelet action in the body. The clinical implications of this drug-drug interaction have been extensively studied; however reported findings are inconsistent. More recently, several studies have questioned whether PPIs are associated with adverse cardiovascular events independent of clopidogrel. Given that PPIs and clopidogrel are widely used, it is critical to better understand the clinical impact of the concomitant treatment with both drugs. This thesis includes four studies that investigate the clinical effects of the drug-drug interaction between clopidogrel and PPIs. Chapter 2, a systematic review and meta-analysis, summarizes findings from 118 studies. Findings do not provide strong evidence for an association between adverse cardiovascular events and the use of PPIs when used alone, in combination with clopidogrel, or in combination with other antiplatelets. Chapters 3, 4, and 5 present analyses of real-world data comprised of electronic medical records. Results of these analyses demonstrate 1) that the concomitant use of clopidogrel and PPIs among inpatients was consistent with clinical guidelines suggested by the FDA (Chapter 3); 2) a lack of association between PPI use vs nonuse and four adverse cardiovascular outcomes among clopidogrel users (Chapter 4); and 3) a lack of association between PPI use vs nonuse and adverse cardiovascular outcomes among prasugrel users or ticagrelor users (Chapter 5). Collectively, our findings do not provide evidence of an elevated risk of adverse cardiovascular outcomes with the combined use of PPIs and clopidogrel. Although pharmacodynamic and pharmacokinetic studies have demonstrated an interaction between these two drugs, our findings support the opinion that the biological interaction does not translate into adverse clinical events among patients with acute coronary syndrome.

Acute coronary syndrome (ACS) refers to a group of clinical conditions caused by myocardial ischemia including unstable angina, non-ST-segment elevation myocardial infarction (NSTEMI), and ST-segmcnt elevation myocardial infarction (STEMI). Appropriate and accurate diagnosis has life-saving implications and requires a quick but thorough evaluation of the patient's history, physical examination, electrocardiogram, radiographic studies, and cardiac biomarkers. The management of patients with suspected or confirmed ACS continues to evolve as new evidence from clinical trials is considered and as new technology becomes available to both primary care physicians and cardiologists. Low- and intermediate-risk patients have frequently been managed in a chest pain center or in the emergency department. While stress testing with or without radionuclide imaging is the most common evaluation method, a CT angiogram is sometimes substituted High-risk patients are often managed with an early invasive strategy involving left heart catheterization with a goal of prompt revascularization of at-risk, viable myocardium. With the increased availability of cardiac catheterization facilities, patients with STEMI are more commonly being managed with primary percutaneous coronary intervention, although thrombolysis is still used where such facilities are not immediately available. This article provides primary care physicians with a concise review of the pathophysiology, clinical evaluation, and management of ACS based on the best available evidence in 2008.

Background: The use of percutaneous left ventricular assist devices in patients with acute myocardial infarction complicated by cardiogenic shock (AMICS) is evolving. The aim of the study was to assess the long-term outcome of patients with AMICS depending on early initiation of Impella CP® support prior to a percutaneous coronary intervention (PCI). Methods: We retrospectively reviewed all patients who underwent PCI and Impella CP® support between 2014 and 2016 for AMICS at our institution. We compared survival to discharge between those with support initiation before (pre-PCI) and after (post-PCI) PCI. Results: A total of 73 consecutive patients (69±12 years old, 27.4% female) were supported with Impella CP® and underwent PCI for AMICS (34 pre-PCI vs. 39 post-PCI). All patients were admitted with cardiogenic shock, and 58.9% sustained cardiac arrest. Survival at discharge was 35.6%. Compared with the post-PCI group, patients in the pre-PCI group had more lesions treated (p=0.03), a higher device weaning rate (p=0.005) and higher survival to discharge as well as to 30 and 90 days after device implantation, respectively (50.0% vs. 23.1%, 48.5% vs. 23.1%, 46.9 vs. 20.5%, p < 0.05). Kaplan–Meier analysis showed a higher survival at one year (31.3% vs. 17.6%, log-rank p-value=0.03) in the pre-PCI group. Impella support initiation before PCI was an independent predictor of survival up to 180 days after device implantation. Conclusions: In this small, single-centre, non-randomized study Impella CP® initiation prior to PCI was associated with higher survival rates at discharge and up to one year in AMICS patients presenting with high risk for in-hospital mortality.

Background. AHA guidelines have been established to reduce Acute Coronary Syndrome (ACS)-related morbidity, mortality and recurrent events post-discharge. These recommendations emphasize the patient as an engaged member of the health care team in secondary prevention efforts. Patients with high levels of activation are more likely to perform activities that will promote their own health and are more likely to have their health care needs met. Despite evidence and strong expert consensus supporting patients as active collaborators in their own ACS care, the complexity and unexpected realities of self-managing one’s care at home are often underestimated. This study seeks to examine the correlates of patient activation at hospital discharge and then identifies activation trajectories in this same cohort in subsequent months. Lastly, this study examines the association between patient activation and health care utilization in the year subsequent to an ACS event. Methods. This study incorporates three aims: Aim 1, identification of the correlates of low patient activation post-discharge; Aim 2, identification of patient activation trajectories among this same cohort in the months following hospitalization; and Aim 3, examination of the association between patient activation and health utilization, post-discharge. Results. Fifty-nine percent of ACS patients identified as being at the lowest two activation stages at the time of hospital discharge. Perceived stress (pidentified post-discharge: low, stable (T1), high, sharp decline (T2), and sharp improvement (T3). The majority of patients (67%) identified as being in T1. Those patients of older age (OR: 2.22; CI 1.4- 3.5), identifying as Black in race (OR: 2.14: CI 1.1- 4.3), and reporting moderate/high perceived stress (OR: 2.54: CI 1.4- 4.5) had increased odds of being in the low, stable trajectory. The bivariate analysis indicated a significant association (P=0.008) between low patient activation and self-reported hospital readmissions in the months following discharge. In the final model, moderate to severe depression (OR: 1.60; CI 1.1- 2.3) was the strongest predictor of readmissions in the 12 months subsequent to discharge. Conclusions: Patients reported low activation at hospital discharge after an ACS event indicated that these patients were not prepared to take an active role in their own care. Correlates of low activation at discharge include moderate to high perceived stress, depression, and low social support. Furthermore, in the months following hospital discharge, the majority of these patients followed either a low/stable or a sharp decline activation trajectory. Hence, these results suggest that over time patients feel less and less confident to take an active role in self-management. Lastly, we found that patient activation may impact healthcare utilization in the year subsequent to hospital discharge, although patient self-reported depression appears to be the strongest predictor of utilization in the subsequent year. Future research is needed to better understand the relationship(s) among patient activation, depression, and health care utilization.

Background: Guideline-concordant therapies for survivors of an acute coronary syndrome (ACS) hospitalization require healthcare access, something that millions of Americans lack. Methods and Results: Using data from a prospective cohort study of over 2,000 survivors of a hospitalization for an ACS in central Massachusetts and Georgia from 2011 to 2013, the first two aims of this thesis sought to identify the post-discharge consequences for survival and health status of having: 1) financial barriers to healthcare, 2) no usual source of care, and 3) transportation barriers. We found that patients lacking a usual source of care and having a transportation barrier were more likely to have died within two years following hospital discharge compared to those without such barriers. Also, patients with financial barriers to healthcare were more likely to experience clinically meaningful declines in physical and mental health-related quality of life over the six months after hospital discharge. The third aim sought to better understand factors influencing the success of care transitions home after an unplanned hospitalization through a qualitative study of 22 patients. Participants described how adequate healthcare access, particularly having insurance and transportation to clinical appointments, facilitated the receipt of follow-up care and adherence to treatments. Conclusions: Limitations in healthcare access may contribute to poorer survival, health-related quality of life, and survival. Additional research is needed to identify interventions to improve healthcare access and test whether improved access leads to better patient outcomes.

Background Acute coronary syndromes (ACS) are a major cause of mortality and morbidity in the developed world. By 2020, ACS will be the leading cause of morbidity and mortality worldwide, largely due to substantial increases in ACS burden in developing countries. The developing world has been under-represented in international ACS registries. The Arabian Gulf area is a part of the developing world where little is known about the epidemiology of ACS. The first aim of the dissertation is to compare ACS patient characteristics, current practice patterns, and in-hospital outcomes in the Arabian Gulf area to a large multinational sample. Patients with an ACS suffer numerous clinical complications that worsen their prognosis. Cardiogenic shock (CS) is the most serious complication of ACS and the leading cause of in-hospital death. Despite advances in therapies; CS hospital mortality rates continue to exceed 50%. The second aim of the dissertation is to describe the characteristics of patients presenting with ACS complicated by cardiogenic shock, their management, and outcomes in a large multinational sample. In recent years, ACS has been increasingly affecting younger patients. While marked age-related differences have been observed in the risk of developing as well as the prognosis of ACS, few studies however examined time trends in the epidemiology of ACS in young adult patients. The third aim of the dissertation is to examine trends in frequency rates, patient characteristics, treatment practices, and outcomes in young adults hospitalized with an ACS. Methods Data from two large multinational registries of patients hospitalized with an ACS were used for this investigation. Nearly 65,000 patients were enrolled in the Global Registry of Acute Coronary Events (GRACE) between 2000 and 2007, while 6,700 patients participated in the Gulf Registry of Acute Coronary Events (Gulf RACE) in 2007. Results Aim1: Patients in Gulf RACE were significantly younger and were more likely to be male, diabetic, and smoke Compared to GRACE. Patients in Gulf RACE were less likely to receive evidence based therapies. Short-term mortality rates were comparable between the two patient cohorts. Aim2: Compared to patients with no CS, patients with CS were more likely to be older, female, have a history of diabetes, and heart failure. Patients with CS were less likely to receive effective cardiac catheterization and adjunctive cardiac medications. In-hospital case-fatality rate of patients with CS were 59.4%. While in-hospital mortality declines over the study period, incidence rates only showed minor declines. Aim2: Baseline characteristics of patients < 55 years of age did not significantly change, while the use of evidence based therapies increased significantly during the years under study. Rates of short-term adverse outcomes and mortality significantly declined over time. Conclusions We observed marked regional differences in the risk profile, clinical management, and outcomes of patients with an ACS internationally compared to the Arab Middle East. Despite the encouraging trends in the use of evidence based therapies which have likely contributed to the improving trends in the prognosis of ACS, rates of development of ACS, as well as mortality due to ACS complications, remain high.

Personcentrerad vård är en av sjuksköterskans kärnkompetenser. Att lindra lidande och att främja hälsa som är ett föränderligt mångdimensionellt fenomen ingår i sjuksköterskans ansvarsområden. Hjärtinfarkt kräver akut behandling och kan påverka vardagliga livet såväl som sex- och samlivet. Det sekundärpreventiva arbetet innefattar bland annat att stödja patient och närstående. Sjuksköterskor har svårigheter att diskutera sexuell hälsa och deras kunskap om hjärtinfarktens inverkan på sexuell hälsa är bristfällig. Syftet var att beskriva upplevelser av sexuell hälsa hos personer som har insjuknat i hjärtinfarkt. Metoden var en litteraturöversikt som utfördes med en systematisk sökstrategi. En integrerad analys av 16 vetenskapliga artiklar genomfördes i syfte att identifiera likheter och skillnader i artiklarnas resultat, vidare för att finna underkategorier och kategorier för att slutligen sammanställa till ett syntetiserat resultat. I resultatet identifierades fyra kategorier; Upplevelser av sexuell funktion, Upplevelser av att samtala om sexuell hälsa, Upplevelser av information från sjukvårdspersonal och Upplevelser av nära relationer. Det framkom minskad lust och lubrikation, svårigheter att få orgasm samt erektil dysfunktion. Det framkom även oro och rädsla för att återuppta sexuella aktiviteter, vilket kunde leda till förändrade sexuella aktiviteter. Det fanns också svårigheter att samtala om sexuell hälsa med sin partner, närstående och sjukvårdspersonal. Informationen framkom som bristfällig och det fanns ökat behov av information om sexuell hälsa. Det framkom också att sexuella relationer förändrades och det fanns ett ökat behov av intimitet med icke sexuella relationer. Även den kroppsliga uppfattningen förändrades och hjärtinfarkten upplevdes påverka existensen. Slutsatsen är att den sexuella hälsan kan påverkas hos personer som har insjuknat i hjärtinfarkt. Med ett personcentrerat förhållningssätt kan sjuksköterskan inom hjärtsjukvård utgå från patientberättelsen och tillsammans med patienten identifiera omvårdnadsbehov samt vidta omvårdnadsåtgärder. / Person-centered care is one of the nurse’s core competencies. Alleviate suffering and promote health, which is a changeable multidimensional phenomenon, are included in the nurse’s responsibilities. Myocardial infarction requires acute treatment and it can affect daily life, as well as the sexual life. Secondary prevention includes supporting the patient and relatives. Nurses have difficulties discussing sexual health and their knowledge about the impact of myocardial infarction on sexual health is insufficient. The aim was to describe experiences of sexual health in people who have had myocardial infarction. The applied method was a literature review which was carried out with a systematic search strategy. An integrated analysis of 16 research articles was conducted in order to identify similarities and differences in the results of the articles, further to find subcategories and categories to finally compile into a synthesized result. Four categories were identified in the result; Experiences of sexual function, Experiences of discussing sexual health, Experiences of information from health care professionals and Experiences of close relationships. It emerged a decreased desire and lubrication, difficulties to have an orgasm and erectile dysfunction. There were also an anxiety and fear of resuming sexual activities, which could lead to altered sexual activities. Difficulties in discussing sexual health with a partner, relatives and health care professionals were also described. Lack of sexual counselling was found with an increased need of information of sexual health following myocardial infarction. It also emerged that sexual relationships were altered and an increased need for intimacy with non-sexual relationships was described. Also the body image altered and myocardial infarction affected the existence. The conclusion is that sexual health can be affected in people who have had myocardial infarction. With a person-centered approach and the patient narrative, the nurse in cardiac care can together with the patient identify nursing needs and take nursing interventions.